3/18/18. Adolescent Hip Injuries. Adolescents with Hip Injuries DISCLOSURES

Transcription

1 Adolescent Hip Injuries Henry Bone Ellis, Jr., MD DFW Sports Medicine Symposium March 24, 2018 DISCLOSURES Royalties and stock options Consulting income Smith and Nephew Other support Research on Osteochondritis Dissecans Allosource Ossur Adolescents with Hip Injuries 1

2 Hip Conditions in the Young Athlete Fracture/Dislocation Sprain/Strains Snapping Hip Hip Impingement Labral Tears Arthritis Athletic Pubalgia Neoplasm Soft Tissue/Overuse Osteonecrosis (Legg-Calves-Perthes Disease) Slipped Capital Femoral Epiphysis (SCFE) Hip Dysplasia Apophysitis Apophyseal Avulsion Epiphyseal Dysplasia Infection Stress Fractures Addie, 13 year old Gymnast 4 Objectives Compare adolescent to adult hips Review specific hip injuries that may be seen in adolescents Discuss overuse conditions in the hip Introduce hip condition prevention The Physis (Growth Plate) of the Hip Proximal Femur Appears at 4-6 mo Fuses at approx 18 y Growth Plate / Physis Triradiate cartilage fuses closes at 12 for girls and 14 for boys 2

3 Growth Curve Tachdijan s 5 th ed 2013 Physis & Apophysis Hip Ossification Centers Secondary Ossificaiton Centers of the Pelvis Female: Male: Median Age of Appearance in years Median Age of Closure in years Greater trochanter <2 15 ( ) Lesser trochanter 6.5 ( ) 12.6 ( ) Anterior inferior iliac spine 14.0 ( ) 14.5 ( ) Ischial tuberosity 12.6 ( ) 20.2 ( ) Anterior superior iliac spine 15.0 ( ) 15.8 ( ) Posterior superior iliac spine 14.4 ( ) 16.5 ( ) Iliac crest 14.4 ( ) 23.3 ( ) Symphysis pubis 17.6 ( ) 27.2 ( ) Greater trochanter 4.1 ( ) 16.8 ( Lesser trochanter 10.9 ( ) 14.1 ( ) Anterior inferior iliac spine 13.6 ( ) 16.3 ( ) Ischial tuberosity 14.0 ( ) 20.6 ( ) Anterior superior iliac spine 14.0 ( ) 14 ( ) Posterior superior iliac spine 14.0 ( ) 18.3 ( ) Iliac crest 14.0 ( ) 21.6 ( ) Symphysis pubis 19.8 ( ) 26.2 ( ) Parvaresh

4 Adolescent Hip Injuries Anna 13 yo F Had severe hip pain and pop/snap after doing the splits Thinks her hip came out of socket No previous injury Club volleyball 11 Hip Pain with an Injury Sports Hernia Labral Tear Hip Injury Strains Sprains Apophyseal Avulsion Fracture Dislocation 4

5 Anna 13 yo F 13 Hip Pain with an Injury 80% are Sprain/Strains around the hip Treatment Rest Short Term Protected Weight Bearing May require physical therapy in higher end athletes Anticipated recovery maybe 2-10 weeks 14 Quadratus Femoris Apophyseal Avulsion Fractures 15 5

6 Tyler 15 yo M Competitive bull rider s/p fall off bull Nondisplaced scaphoid fracture Left buttock pain Apophyseal Avulsion Fractures Iliac Crest ASIS AIIS Lesser Trochanter Greater Trochanter Ischial Tuberosity 6

7 Iliac Crest Apophyseal Avulsion Anterior Superior Iliac Spine (ASIS) Anterior Inferior Iliac Spine (AIIS) 7

8 Why is there residual pain following AIIS? Residual Pain Subspinal Impingement HALTAR Lesion Rectus Tendonitis FAI Ischial Apophyseal Injury Poorly tolerated if widely separated Howard and Piha JAMA 1965 Schlongsky and Olix 1972 Miller A et al JBJS 1987 Wootton JBJS 1990 AAOS Annual Meeting 2012 Ischial Apophyseal Injury Transverse incision Subgluteal approach Mobilize fragment Fixation with cannulated screws 8

9 Ischial Apophyseal Injury Post-Operative Rehabilitation Protect Hip Flexion and Knee Extension Hinged knee brace in flexion Limited active knee flexion or stairs for 8 weeks Gradual strengthening Return to play 3-5 months Alfonso, 16 yo M Landing on his hip playing soccer 3 months ago Continued groin pain Cannot kick the ball Pain with sitting for prolonged period of time 26 Adolescent Impingement Not new concept Tilt deformity correlated to athletics 27 9

10 Adolescent Impingement Prevalence of is similar to adults Approximately 30% have alpha angle > 55 degrees age % have focal retroversion Adolescent Impingement 64 adolescents athletes (< 16 y) 19 of 64 with open physis No complications were noted at 2 years 8 patient required 2nd look arthroscopies All females Overuse Injuries

11 Addie Signs of hyperlaxity No pain or abnormal findings on exam What causes the popping? Show me the popping OR Snapping Hip Syndrome Internal Snapping Hip or Coxa Sultans Internus - Iliopsoas External Snapping Hip or Coxa Sultans Externus - Iliotibial band 11

12 Internal Snapping Hip - Internal Snapping Hip: Coxa Sultans Internus - Iliopsoas Abduction External Rotation Flexion Internal Snapping Hip Internal Snapping Hip 12

13 Internal Snapping Hip - Internal Snapping Hip: Coxa Sultans Internus - Iliopsoas - Audible/groin pain - Dancer, tumblers - Treatment: - Reassurance - Hip flexor stretching - Thomas Stretch External Snapping Hip - External Snapping Hip or Coxa Sultans Externus - Iliotibial band - Popping with walking - Runners - Described as hip pops in and out - Visualize External Snapping Hip 13

14 External Snapping Hip - External Snapping Hip or Coxa Sultans Externus - Iliotibial band - Popping with walking - Runners - Described as hip pops in and out - Visualize - Treatment: - IT band stretching - Foam Rolling Snapping Hip Syndrome Reassurance if not symptomatic [Overuse Injury] Treatment includes Activity Modification Stretching Counseling Nutrition Conditioning Physical Therapy if needed Rest if needed Snapping Hip Syndrome Ober Ober FR JAMA

15 External Snapping Hip External: IT Band IT Stretch NSAIDs Lengthening -Byrd 2005 Can we prevent hip problems in adolescents? Development of Hip Impingement Siebenrock et al basketball players 76 asymptomatic controls 10 fold increase in CAM deformity 15

16 Development of Impingement Age matched cohort Activity (Sports) gave 10-fold higher risk of alpha angle > 55 Extension of proximal femoral physis gave rise to the cam lesion 46 Development of Impingement Agricola AJSM 2014 Development of Hip Impingement and Sports Systematic Review - 9 Studies (Nepple) High-level male 2-8x more likely Development of signs of hip impingement in youth hockey over 3 years with serial MRI (Philippon) Tennis Players Played tennis longer increase risk of hip impingement Signs of hip impingement may be a risk for ACL injury (Beaulieu) Nepple AJSM

17 Protect our Young Athletes Avoid sports specialization Encourage free play Avoid year round play Encourage off season Proper warm up and conditioning Thank You Scottish Rite for Children Pediatric Orthopedics and Sports Medicine Center Opening October 2018 scottishritehospital.org/sports 17